Breast & Endocrine Surgery

These two subjects are examined together because they share a surgical logic: both deal with lumps in glands, and in both the mistake that costs marks is acting on the lump before completing the assessment.

The organising tool has two halves. In the breast, nothing is decided without triple assessment. In endocrine surgery, function is established before structure is touched.

Both rules exist because of the same failure. A breast lump that feels benign may be malignant, and a thyroid or adrenal lump that looks operable may be secreting a hormone that will kill the patient on the table.

1. Triple Assessment

Triple assessment means clinical examination, imaging and pathology, each scored independently, on the same visit wherever possible.

The whole point is that the three components are independent. A benign examination does not permit skipping the biopsy, because each modality misses a different subset of cancers, and only concordance across all three is reassuring.

If any one component is suspicious, the lesion is treated as suspicious regardless of the other two.

Ultrasound is preferred under the age of about forty because dense young breast tissue is radiologically opaque, reducing the sensitivity of mammography to the point where it may be falsely reassuring.

Mammography is preferred in older women, where fatty replacement gives good contrast and microcalcification is visible.

Core biopsy has largely replaced fine needle aspiration because it provides architecture as well as cytology. That means it distinguishes invasive carcinoma from ductal carcinoma in situ, and it supplies tissue for receptor testing, neither of which aspiration can do.

2. Benign Breast Disease

Most breast lumps are benign, and the patterns are distinguished by age, mobility and consistency.

A fibroadenoma occurs in a young woman, is firm, smooth, highly mobile and painless, and is often called a breast mouse for that mobility. It requires triple assessment and then usually only reassurance.

A phyllodes tumour looks similar but occurs in an older age group, grows rapidly, and can be benign, borderline or malignant. It is treated by wide local excision because it recurs after simple enucleation.

A breast cyst presents as a smooth, sometimes tender lump that disappears on aspiration. If the fluid is bloodstained, or a residual lump remains after aspiration, further assessment is mandatory.

Fibrocystic change produces bilateral, cyclical lumpiness and pain and is a physiological variation rather than a disease.

A duct papilloma is the commonest cause of blood-stained single-duct nipple discharge, and although usually benign, it requires excision because the same presentation can be produced by carcinoma.

Fat necrosis follows trauma, produces a hard irregular lump that tethers skin, and mimics carcinoma so closely that it can only be excluded by biopsy.

Mammary duct ectasia produces a thick greenish discharge in a perimenopausal woman with dilated subareolar ducts, and periductal mastitis is its inflammatory counterpart, strongly associated with smoking.

Lactational mastitis is treated with continued feeding, analgesia and antibiotics covering Staphylococcus aureus. A breast abscess is drained, and increasingly by repeated needle aspiration under ultrasound rather than incision.

Gynaecomastia is true glandular proliferation in the male, and it is a drug and endocrine problem before it is a surgical one. It reflects a shift in the ratio of oestrogen to androgen rather than an absolute excess of either.

Physiological causes are neonatal, pubertal and senile, and all are self-limiting. Pathological causes include cirrhosis, hypogonadism, testicular and adrenal tumours, and a long drug list that includes spironolactone, digoxin, cimetidine, ketoconazole and antiretroviral therapy.

A unilateral, hard, eccentric mass in a man is not gynaecomastia and requires triple assessment, because male breast cancer exists and presents late with early skin and chest wall involvement given the small volume of tissue.

3. Breast Carcinoma

Breast cancer is the commonest malignancy in Indian women and presents at a younger age and a later stage than in Western populations, largely because organised screening is absent.

The commonest histological type is invasive carcinoma of no special type. Invasive lobular carcinoma is important out of proportion to its frequency because it grows diffusely rather than as a mass, is often mammographically occult, and is more often bilateral and multifocal.

Clinical features reflect the anatomy. Tethering of skin occurs through the suspensory ligaments; nipple retraction through ductal infiltration; peau d orange through dermal lymphatic obstruction; and fixity to chest wall through invasion of pectoralis.

Paget disease of the nipple is an eczematous change of the nipple itself that indicates underlying ductal carcinoma. The distinguishing feature from eczema is that eczema spares the nipple and affects the areola, whereas Paget disease begins at the nipple.

Inflammatory breast cancer presents as a red, swollen, warm breast that is mistaken for mastitis, and is staged as locally advanced disease from the outset.

Spread is to the axillary nodes principally, to the internal mammary chain from medial tumours, and distantly to bone, lung, liver and brain. Bone is the commonest distant site, and lesions are typically osteolytic.

4. Receptors and Treatment

Breast cancer treatment is decided by three receptors, not by size alone.

Endocrine therapy differs by menopausal status, and the reason is mechanistic. Tamoxifen is a selective oestrogen receptor modulator used in premenopausal women; aromatase inhibitors are used in postmenopausal women.

Aromatase inhibitors block peripheral conversion of androgens to oestrogen, which is the main source of oestrogen after the menopause but not before it, so they are ineffective in a woman with functioning ovaries.

Tamoxifen carries a small but real risk of endometrial carcinoma and of venous thromboembolism, because it is agonistic at the endometrium while antagonistic at the breast.

Surgery is either breast conserving with radiotherapy, or mastectomy. Breast conservation with radiotherapy gives equivalent survival to mastectomy, and the choice therefore turns on tumour to breast size ratio, multifocality and patient preference rather than on cure rates.

Radiotherapy after conservation is not optional. Omitting it raises local recurrence substantially, so a patient unable or unwilling to complete radiotherapy is not a candidate for conservation.

A strong family history changes the operation as well as the surveillance. BRCA1 and BRCA2 mutations carry a high lifetime risk of breast and ovarian cancer, and BRCA1 tumours are disproportionately triple negative and therefore not amenable to endocrine therapy.

Carriers are offered intensified surveillance from a young age, and risk-reducing bilateral mastectomy and salpingo-oophorectomy are discussed, the latter also reducing breast cancer risk by removing the main premenopausal source of oestrogen.

5. The Axilla

Axillary staging is the strongest single prognostic factor, but the surgery that provides it causes lymphoedema, so practice has moved steadily towards doing less.

Sentinel lymph node biopsy has replaced routine axillary dissection in the clinically node-negative axilla. The sentinel node is identified with blue dye, radioisotope or both, and if it is free of tumour the rest of the axilla is spared.

The ACOSOG Z0011 trial then went further, showing that women having breast conservation with only one or two positive sentinel nodes, who receive whole-breast radiotherapy and systemic therapy, gain no survival benefit from completion axillary dissection.

More recently the SOUND trial showed that sentinel node biopsy itself can be omitted in small tumours with a negative preoperative axillary ultrasound, with axillary recurrence around 0.4 per cent at five years.

Axillary clearance remains indicated for clinically or cytologically proven bulky nodal disease.

The complications of clearance are worth knowing precisely: lymphoedema, seroma, injury to the long thoracic nerve producing winged scapula, injury to the thoracodorsal nerve weakening latissimus dorsi, and numbness over the medial arm from division of the intercostobrachial nerve.

6. Function Before Structure

Endocrine surgery reverses the usual order of assessment. In most of surgery you image a lump and then decide what it is. In endocrine surgery you establish what the gland is doing before you image or biopsy it.

Three examples make the rule concrete. A thyroid nodule in a patient with a suppressed thyroid stimulating hormone is investigated with a scan rather than a needle. A phaeochromocytoma is blocked pharmacologically before it is touched. A parathyroid is localised only after biochemistry has proved the diagnosis.

Each of those is a question the examination asks in some form almost every year.

7. The Thyroid Nodule

The first test in a thyroid nodule is thyroid stimulating hormone, not ultrasound and not a needle.

If it is suppressed, the nodule may be autonomously functioning, and a radionuclide scan is performed. A hot nodule is almost never malignant and is treated for hyperthyroidism rather than aspirated.

If the hormone level is normal or raised, ultrasound is performed and the nodule is scored for suspicious features: solid composition, hypoechogenicity, taller-than-wide shape, irregular margins and microcalcification.

Fine needle aspiration is then reported by the Bethesda system, now in its third edition, in six categories: nondiagnostic, benign, atypia of undetermined significance, follicular neoplasm, suspicious for malignancy, and malignant.

The critical limitation is that cytology cannot diagnose follicular carcinoma. Follicular adenoma and follicular carcinoma have identical cells, and the distinction rests entirely on capsular or vascular invasion, which requires the whole capsule to be examined histologically.

That is why a follicular neoplasm on aspiration leads to hemithyroidectomy as a diagnostic procedure rather than to a definitive answer.

Medullary carcinoma requires exclusion of a phaeochromocytoma before operating, because it occurs within multiple endocrine neoplasia type 2 and removing the thyroid first can precipitate a hypertensive crisis from an unrecognised adrenal tumour.

Papillary carcinoma is the commonest and has the best prognosis. Lymph node metastasis, unusually, does not worsen survival greatly, which is why nodal disease is treated but does not reclassify the patient as incurable.

8. Thyroidectomy and Its Complications

Surgery is indicated for malignancy, for compressive symptoms, for retrosternal extension, for cosmetic reasons, and for hyperthyroidism where drugs and radioiodine are unsuitable.

A hyperthyroid patient must be rendered euthyroid before operation, using antithyroid drugs, with beta blockade and sometimes iodine, because operating on an untreated gland can precipitate thyroid storm.

Lugol iodine given for a week or two before surgery reduces gland vascularity and firms the tissue, which is a mechanical rather than a hormonal benefit.

The complications follow the anatomy and are examined relentlessly.

Recurrent laryngeal nerve injury causes hoarseness when unilateral. Bilateral injury is the emergency, because both cords lie in the midline and the airway obstructs, requiring immediate reintubation.

External branch of the superior laryngeal nerve injury removes tension from cricothyroid and causes loss of high pitch, which matters to singers and is easily missed on routine review.

Hypocalcaemia follows parathyroid removal or devascularisation, appears within one to three days, and presents with perioral tingling, then carpopedal spasm, then the Chvostek and Trousseau signs.

Postoperative haematoma is the true surgical emergency. It compresses the airway, and the correct response is to open the wound at the bedside immediately rather than to transfer the patient to theatre first.

Thyroid storm presents with fever, tachyarrhythmia, agitation and eventually cardiovascular collapse, and is treated with beta blockade, antithyroid drugs, iodine given after the antithyroid drug, and corticosteroids.

The order matters: iodine given before the antithyroid drug supplies substrate for further hormone synthesis.

9. Parathyroid and Adrenal

Primary hyperparathyroidism is caused by a single adenoma in the great majority of cases, with hyperplasia and carcinoma much rarer. It produces hypercalcaemia with an inappropriately normal or raised parathyroid hormone.

The classical description of bones, stones, abdominal groans and psychic moans still applies, but most cases are now found incidentally on biochemistry.

Localisation follows diagnosis rather than preceding it. Sestamibi scanning and ultrasound are used to plan a focused operation, not to make the diagnosis, and a negative scan in a biochemically proven case does not exclude the disease.

Secondary hyperparathyroidism is the appropriate response to chronic kidney disease, with low or normal calcium. Tertiary disease is autonomous secretion after prolonged secondary stimulation, with calcium now high.

Phaeochromocytoma classically produces episodic headache, sweating and palpitations with hypertension, and is diagnosed by plasma or urinary metanephrines rather than by catecholamines, because metanephrines are produced continuously and catecholamines are released in bursts.

Alpha blockade must precede beta blockade, and this is one of the most frequently examined points in endocrine surgery. Beta blockade alone leaves alpha-mediated vasoconstriction unopposed and can precipitate a hypertensive crisis.

Phenoxybenzamine is given for one to two weeks with liberal salt and fluid, because the chronically vasoconstricted patient is volume depleted and will become profoundly hypotensive when the tumour is removed and catecholamine levels collapse.

Multiple endocrine neoplasia syndromes tie these together: type 1 comprises parathyroid, pancreatic and pituitary tumours; type 2A medullary thyroid carcinoma, phaeochromocytoma and parathyroid disease; type 2B substitutes mucosal neuromas and a marfanoid habitus for the parathyroid component.

10. Worked Examples

Example 1. A 32-year-old woman has a firm, smooth, highly mobile 2 cm breast lump. Ultrasound is reported as benign. What next.

Two components of triple assessment are complete and both suggest a fibroadenoma, but the assessment is not finished. Core biopsy is still required, because the three components are scored independently and concordance across all three is what provides reassurance.

Ultrasound rather than mammography is correct at this age because dense glandular tissue reduces mammographic sensitivity. If the biopsy confirms a fibroadenoma, reassurance is sufficient and excision is not required.

Example 2. A patient with a thyroid nodule has a thyroid stimulating hormone of 0.05. The house officer requests fine needle aspiration.

This is the wrong next step. A suppressed hormone level raises the possibility of an autonomously functioning nodule, and the correct investigation is a radionuclide scan.

A hot nodule is almost never malignant, so aspirating it generates an unnecessary result and may produce a false positive from the hypercellularity of a functioning nodule. Treatment is directed at the hyperthyroidism instead.

Example 3. A patient with medullary thyroid carcinoma is listed for total thyroidectomy. What must be done first.

Plasma or urinary metanephrines must be measured to exclude a phaeochromocytoma, because medullary carcinoma occurs within multiple endocrine neoplasia type 2.

If a phaeochromocytoma is present it is treated first, with alpha blockade before beta blockade and volume repletion, and the adrenal tumour is removed before the thyroid. Operating on the thyroid first risks a fatal intraoperative hypertensive crisis.

Summary

• In the breast, triple assessment; in endocrine surgery, function before structure.
• The three components of triple assessment are scored independently, and any one suspicious result governs.
• Ultrasound under about forty, mammography above it, because young breast tissue is dense.
• Core biopsy gives architecture and receptors; aspiration cannot distinguish invasive from in situ disease.
• Fibroadenoma is mobile and young; phyllodes is older, faster and needs wide excision.
• Duct papilloma is the commonest cause of bloody single-duct discharge but must still be excised.
• Fat necrosis mimics carcinoma and can only be excluded by biopsy.
• Gynaecomastia reflects an oestrogen to androgen ratio shift and is often drug induced.
• A hard eccentric mass in a man is not gynaecomastia and needs triple assessment.
• Lobular carcinoma is often mammographically occult, bilateral and multifocal.
• Paget disease begins at the nipple; eczema spares it.
• Bone is the commonest distant metastatic site and lesions are osteolytic.
• Treatment is decided by oestrogen, progesterone and HER2 status.
• Tamoxifen for premenopausal women, aromatase inhibitors for postmenopausal.
• Tamoxifen carries endometrial carcinoma and thromboembolism risk.
• Conservation with radiotherapy equals mastectomy for survival; radiotherapy is not optional.
• BRCA1 tumours are disproportionately triple negative, so endocrine therapy is unavailable.
• Sentinel node biopsy has replaced routine clearance in the node-negative axilla.
• Z0011 removed completion clearance for one or two positive nodes after conservation.
• SOUND allows omitting sentinel biopsy in small tumours with negative axillary ultrasound.
• Clearance risks lymphoedema, winged scapula and medial arm numbness.
• Thyroid stimulating hormone is the first test in a thyroid nodule.
• A hot nodule is almost never malignant and is not aspirated.
• Cytology cannot distinguish follicular adenoma from carcinoma; only capsular invasion can.
• Papillary spreads by lymphatics with excellent prognosis; follicular spreads by blood.
• Medullary carcinoma requires exclusion of phaeochromocytoma before surgery.
• Render a hyperthyroid patient euthyroid before operating.
• Bilateral recurrent laryngeal nerve injury obstructs the airway.
• Superior laryngeal nerve injury removes high pitch.
• Postoperative haematoma is opened at the bedside, not in theatre.
• Iodine is given after the antithyroid drug in thyroid storm, never before.
• Primary hyperparathyroidism is usually a single adenoma; localisation follows diagnosis.
• Phaeochromocytoma is diagnosed by metanephrines, and alpha blockade always precedes beta blockade.